Integrating Behavioral Health in Primary Care Using Lean Workflow Analysis: A Case Study

This paper describes the practice change approach that evolved into the PCORI IBH-PC intervention.

Integrating Behavioral Health in Primary Care Using Lean Workflow Analysis: A Case Study

Constance van Eeghen, Benjamin Littenberg, Melissa D. Holman, and Rodger Kessler

J Am Board Fam Med May-June 2016; 29:385-393; doi:10.3122/jabfm.2016.03.150186

Background: Primary care offices are integrating behavioral health (BH) clinicians into their practices. Implementing such a change is complex, difficult, and time consuming. Lean workflow analysis may be an efficient, effective, and acceptable method for use during integration. The objectives of this study were to observe BH integration into primary care and to measure its impact.

Methods: This was a prospective, mixed-methods case study in a primary care practice that served 8,426 patients over a 17-month period, with 652 patients referred to BH services. Secondary measures included primary care visits resulting in BH referrals, referrals resulting in scheduled appointments, time from referral to the scheduled appointment, and time from the referral to the first visit. Providers and staff were surveyed on the Lean method.

Results: Referrals increased from 23 to 37 per 1000 visits (P < .001). Referrals resulted in more scheduled (60% to 74%; P < .001) and arrived visits (44% to 53%; P = .025). Time from referral to the first scheduled visit decreased (hazard ratio, 1.60; 95% confidence interval, 1.37–1.88) as did time to first arrived visit (hazard ratio, 1.36; 95% confidence interval, 1.14–1.62). Survey responses and comments were positive.

Conclusions: This pilot integration of BH showed significant improvements in treatment initiation and other measures. Strengths of Lean analysis included workflow improvement, system perspective, and project success. Further evaluation is indicated.

Building momentum

It's been a good week here in Vermont for the IBH-PC team. We had a great "kick-off" call with the staff from PCORI (Els Houtsmuller, Alex Hartzman, Iris Giggetts and Michelle Johnston-Fleece) who taught us all about how PCORI is organized and finances and reporting and contracting and milestones and such.

Juvena Hitt, Project Manager and IRB Wizard

Then, on Friday, UVM's IRB approved the research protocol.  This happened much faster than we expected, thanks in large part to the expert efforts of Juvena Hitt. Now we can proceed with coordinating the dozens of other IRBs that need to approve the identical protocol.

As I described in a previous post, the research effort is divided into seven teams. This week, I'd like to tell you about the Executive Team which is tasked with setting policy, making strategic decisions and coordinating all the other teams. The team has met weekly for the last several months. It includes:

• Abigail Crocker, Statistician
• Sylvie Frisbie, Research Associate
• Juvena Hitt, Project Manager
• Jen Lavoie, Co-investigator
• Ben Littenberg, Principal Investigator
• Rodger Kessler, Co-PI
• Connie van Eeghen, Project Director
• Jon van Luling, Research Assistant

So far, the team has:

• Organized the teams
• Established internal group norms
• Established online communication & documentation tools (including this blog!)
• Secured the prime contract with PCORI
• Drafted subcontracts and agreements with consultants, non-UVM coinvestigators at other sites
• Refined criteria and process for site participation (“on-boarding”)
• Reviewed the first draft educational modules

and thanked our lucky stars for our great collaborators all over the country!

Best wishes and happy integrating,

Ben

It's alive!

We have received the signed contract from PCORI (backdated to April 1, thank you very much) that makes the project official.

Of course, many of us have been busy behind the scenes for many months getting ready to kick this machine into high gear.  They include 16 investigators, 3 consultants, 6 project staff, 9 site cluster leaders, 15 advisors, and many support staff at UVM and the collaborating institutions around the country. Soon, we will have site leaders and staff from 40 clinical sites as well, not to mention our sponsors at PCORI who put in great efforts to get this complex proposal through approval process.

Getting organized is a big challenge, so we have taken a divide-and-conquer strategy.  We split the work into 7 areas: Site Management, Practice Change, Education, Evaluation, Engagement, Dissemination, and an Executive team to coordinate it all.  The teams are being activated sequentially to try to keep the chaos to a minimum. Over the next few weeks, I will post descriptions of the teams and what they will be doing.

In the meantime, we are

• putting together the subcontracts and work agreements that move funds from the prime contractor (UVM) to the various other participants and institutions. 
• developing communication methods to keep all 90+ participants in the loop.
• planning an investigators' meeting for August 25-26 in Burlington
• developing the educational modules that form a big part of the intervention
• refining the toolkit for the practice redesign teams
• meeting with cluster leaders to identify and on-board the clinical sites
• finalizing the data abstraction details,
• recruiting a post-doctoral fellow, and
• doing other stuff that I can't even remember right now...

So, please subscribe to the blog because I hope it will be the main way we do group communications. Feel free to comment, ask questions, make suggestions, post recipes or whatever else you like.

As always, thanks for your support.

Ben